Provider First Line Business Practice Location Address: 
2390 MITCHELL PARK DR
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
PETOSKEY
    Provider Business Practice Location Address State Name: 
MI
    Provider Business Practice Location Address Postal Code: 
49770-8965
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
231-487-9090
    Provider Business Practice Location Address Fax Number: 
231-487-9191
    Provider Enumeration Date: 
10/31/2006